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About this book

Forces such as political conflict, globalisation and the growth of the internet, offering news of life elsewhere, mean levels of migration are higher now than at any other time in history. Despite the signing of a number of legally binding international treaties that seek to guarantee health care for migrants, there is still a considerable gap between government commitments and the reality of everyday life. As levels of migration continue to increase, it is essential for health care professionals to consider the differing needs of migrants in order to provide them with quality care.

Informed by systemic theory, and drawing on the author's extensive clinical – as well as personal – experience, this timely book explores the limited existing information about migrants' health care experiences. Providing a comprehensive insight into a worldwide issue, this is an essential guide for health care students, professionals and policy makers.

Table of Contents

1. Introduction

Abstract
The phenomenon of international migration is not new: migrations have occurred throughout human history, beginning with the movements of the first human groups from origins in East Africa to their current location in the world. However, the forces of globalization, economics, political conflict and growth of the Internet and social networks offering news of life elsewhere mean more people are on the move now than at any other time in history. In 2013, the International Organization for Migration estimated there were 232 million international migrants1 worldwide, with nearly 50% living in the more developed countries of the world (IOM, 2013). This is predicted to rise to 405 million by 2050. This pattern is reflected in Britain as well: in 2014 approximately 12.5% of the population was born abroad, compared with 8% in 2001. The net long-term migration to the UK was estimated to be 260,000 for the year ending June 2014, with immigration of people from the EU countries increasing by 45,000, and non-EU by 30,000. Until recently, most migrants were assumed to be adult men. However, as reflected in the UN International Migration Report, 48% of all migrants in 2013 were women and 15% were under the age of 20.
Jenny Altschuler

2. Links Between Migrancy and Health

Abstract
The diverse nature of migrant experiences means that attempts to understand the links between migrancy and health have yielded contradictory findings. A wide body of research and clinical studies suggests that, overall, the outcomes for physical and mental health are worse for non- UK born individuals residing in the UK compared to the rest of the UK population. However, others suggest that changes in the health and health behaviours of migrants are not as marked or linear as generally assumed, and cannot be understood without considering other factors, including socio-economic circumstances and the immigration regulations of the countries to which migrants move (Gushulak, Pace and Weekers, 2010; Thomas and Gideon, 2013). Some of these contradictions relate to difficulties in monitoring and recording migrant health, differences in definitions of ‘the migrant’ and using concepts like ethnicity as a proxy for migrant status. Consequently, this chapter begins by discussing the complexities of monitoring migrant health and entitlements to health care, before discussing key trends emerging from studying physical and mental health.
Jenny Altschuler

3. Individual and Family Experiences of Illness and Death

Abstract
The diagnosis of a life-limiting illness tends to have a profound effect on one’s experience of self and relationship with others (Bury, 1982). Finding out one has a life-limiting condition (or that one’s child or another loved one is seriously ill, significantly impaired and/or may die) can give rise to a range of powerful emotions including shock, anger, anxiety and fear: fear of the pain and other symptoms associated with the disease, of losing control, becoming increasingly dependent, intolerant, driving one’s partner (or another loved one) away, and of dying. Being ill confronts one with changes in experiences of embodiment, with the confusion of becoming someone different even though one is still the same person (Swoboda, 2006). This sense of disruption is not only relevant to situations of actual illness: many ‘previvors’ report a similar sense of disruption on being told they have a genetic predisposition to developing life-limiting conditions, as for example when blood tests reveal mutations to the BRCA 1 or 2 gene, signifying one has hereditary breast-ovarian cancer syndrome (Hamilton, Moyer and Lobel, 2009). Some people respond by drawing on beliefs and memories that help to maintain a sense of continuity between the past, present and future. In other cases, illness becomes a ‘turning point’ (Le Shan, 1989), opening up the possibility of changes that lead to a more comfortable and fulfilling experience of self and relationship with others.
Jenny Altschuler

4. Cultural Diversity, Language Barriers and Prejudice

Abstract
As Britain’s Asian, West Indian and African populations have grown, and the influx of people from EU countries has increased, many health care professionals, particularly those in inner city areas, are working with populations in which a greater proportion of people belong to ethnic minority groups. Consequently it is no longer a question of whether or not Britain is a multicultural society: it is a question of how we engage with the tensions and opportunities that arise from living in a society in which people have different cultural backgrounds (Rober and de Haene, 2014) and, in some cases, diverse constructions of health, illness and health care. There will always be differences between the experience and understanding of ‘insiders’ and outsiders’ to any particular cultural grouping. However, it is important to ensure we have sufficient ‘cultural competence’ to be able to engage sensitively and effectively with the people with whom we work. ‘Cultural competence’ was first used by Cross (1988) but it was not until about a decade later that greater emphasis was placed on applying this concept to health care and the training health care professionals (Betancourt, Green and Carrillo, 2000; Kai, Beavan and Faull, 2011; Papadopoulos, Tilke and Taylor, 1998; Srivastana, 2007).
Jenny Altschuler

5. Individual and Family Experiences of Migration

Abstract
Most of the earlier attempts to understand the causes, processes and consequences of migration were aimed at establishing a model that would be applicable to all forms of migration. That was at a time when travel and communication were less available and most migrants were expected to settle in the country to which they moved. Since then, the rates of migration have intensified, with greater numbers of migrants and refugees drawing from and moving to an ever-widening number of countries. At the same time, the globalization of production, distribution, exchange and evolution in technology and social networking have opened up societies in ways that were unimaginable before (Braziel and Mannur, 2003). As such, most people’s lives are bound up with the entanglements and consequences of dispersion at some level (Brah, 1996). Diasporic studies have had a considerable impact on understandings of migration. The concept of diaspora refers to the longing and mental fragmentation experiences of dispersion tend to evoke.
Jenny Altschuler

6. Intersection Between Migration and Illness

Abstract
This chapter focuses on the intersection between experiences of illness and migration. The case examples discussed here illustrate that when difficulties arise, placing migration and its consequences central to discussions about illness and mortality can help to construct a less pathologizing understanding of self, family and others. They draw attention to the importance of listening, bearing witness to pain and exploring the impact of the past on the present. However, they also illustrate the need to highlight stories of strengths and resilience and attend to transference and counter-transference phenomena: to personal resonances with the experiences of the people with whom we are working. The philosopher Derrida (2000) proposes that the foreigner is a figure that questions our own existence and belonging: he speaks of an otherness that is not a spatial problem but relates to the cultural and experiential distance between you and me.
Jenny Altschuler

7. Working With Migrant Patients in General Practice

Abstract
As a general practitioner (GP) in inner city London, the majority of my work is with patients who are first- or second-generation migrants to the UK. My interest in this area of work was initially sparked as a new GP, some two decades ago, finding consultations with patients from different cultures fascinating but also frustrating. I would often end a consultation with the feeling that despite my best efforts and the use of an interpreter when required, I had somehow failed to meet my patient’s expectations, or to understand something they had been telling me. Sometimes patients were clearly cross and frustrated with me; sometimes I just had a feeling that communication had not gone well, and sometimes patients returned without following my advice. I realized that although my education as a doctor had been comprehensive biomedically, and my training as a GP had covered a more holistic ‘bio-psycho-social’ approach (Brody, 1999) as well as considering the interrelationship between doctor and patient (Balint, 1957), I had very little education on working across cultures. About this time, I took a course in systemic approaches to working in general practice and developed an interest in narrative and systemic approaches in the consultation, initially under the tutelage of John Launer, who has written widely in this area (Launer, 1995, 1996, 2002).
Rachel Hopkins

8. International Health Care Migration

Abstract
The strengthening of global labour markets means that a considerable number of people who migrate are highly skilled professionals. Whilst doctors, nurses, physiotherapists, and other health care professionals represent a small proportion of this group, the migration of health care professionals has had a significant effect on the health care systems of ‘destination’29 as well as ‘source’30 countries, the countries in which professionals like myself were born, trained and decided or felt forced to leave (McElmurry et al., 2006; Ormond, 2013; Shah, 2013). Many health professionals who migrate go on to develop successful careers and establish a comfortable life for themselves and their families. Indeed, a high proportion of people who reach the top of their field were born and trained outside of the UK. However, regardless of whether the move is permanent or temporary, it can be extremely difficult dealing with the ‘double culture shock’, with the excitement, anxiety, confusion and insecurity of having to adapt professionally as well as personally (Austin, 2005; Guru et al., 2012).
Jenny Altschuler

9. Conclusion

Abstract
Despite the introduction of increasingly restrictive policies, economic imbalances, political conflict, demographic patterns and international population mobility mean migration and its consequences for the health of migrants and their non-migrant relatives are facts of global life. However, discussions about the health care of migrants have the potential to unsettle understandings of nationhood and civil rights, touching on moral and political debates about responsibility of a nation state to provide equitable health care to everyone residing in that country. This includes debates about whether vulnerable people whose right to remain in the country is contested should have access to free medical care when they are unable to pay, whether the state should provide interpreters or require migrants to learn English, and anxiety about the increased prevalence of conditions like tuberculosis (TB), raising questions about how we think of ‘them’ and ‘us’, and the distribution of limited resources (Haour-Knipe, 2013).
Jenny Altschuler
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